Trump is dismissing a top voter concern

Robert Mueller. Iran. North Korea. Stormy Daniels. These are the issues you’ll hear about if you flip on the news or hop on Twitter.

But that’s not what people in real America care about the most. Several surveys show health care cost and availability are a top concern of voters heading into the November midterm elections, with some key indicators getting worse instead of better. Recent research by Deutsche Bank found that health care has been the most-Googled political topic so far in President Trump’s first term, followed by Mueller (the special counsel investigating Russian interference in the 2016 elections) and immigration. In an April YouGov/HuffPost poll, health care was the top voter concern, followed by the economy, gun policies and immigration.

Everybody knows why. Soaring costs are an unmitigated worry for many families, even those with good insurance. The average deductible for patients with employer-provided coverage rose 397% from 2006 through 2017, to $1,505, according to the Peterson-Kaiser Health System Tracker. Out-of-pocket spending for people with insurance has risen more than twice as much as wages during the last decade. The cost of health benefits as a portion of total employee compensation has been going up, one reason many economists think wages themselves have been stagnant.

The portion of Americans without health insurance jumped from 10.9% to 12.2% between 2016 and 2017, according to Gallup. That was the biggest rise in the uninsured population in a decade, and it followed several years of sharp declines after the Affordable Care Act went into effect in 2014. Even with the ACA, there are about 28 million Americans who don’t have insurance (as of 2016).

Stuck in the middle

One group enduring especially punishing cost increases are those who don’t get insurance through an employer and buy it individually, while making too much money to qualify for subsidies under the ACA. These are typically individuals or families with incomes above $100,000 who have virtually no leverage to bargain with insurers, the way big companies do. As Yahoo Finance and others have reported, policies can cost $30,000 a year or more, with additional out-of-pocket costs. Those over 50 seem to pay the most. About 10 million Americans are covered by unsubsidized individual policies.

President Trump’s most prominent effort on health care was last year’s failed attempt kill to the Affordable Care Act. And there’s a chance Republicans in Congress might try again this year. But that wouldn’t do anything to help with costs, and it would leave some 20 million people stuck finding other ways to pay for coverage. Many wouldn’t, or couldn’t.

The GOP tax bill that Trump signed at the end of 2017 will end the ACA’s “individual mandate” requiring everybody to have insurance or assert a legitimate exemption, beginning next year. So people who don’t want to pay for insurance will no longer have to. That will save them the cost of premiums, but for some it will backfire, since they’ll get hurt or sick and have to come up with thousands to pay for care. Repealing the mandate, meanwhile, could push premiums even higher for people who do want coverage, because those who go without will probably be healthier, leaving behind sicker people costing more to insure.

Trump has also proposed new types of “skinny” plans that cover limited services, for a lower up-front cost. But many health experts deride such plans as “junk insurance” that barely even functions as insurance, because they often don’t cover the kind of costs that can torpedo family budgets if something goes wrong. And this, too, would probably push premiums higher for those who want comprehensive policies, since, again, it would be healthier people leaving the market for traditional insurance, with sicker, costlier patients remaining.

A bill to restore subsidies gone nowhere

Senators Lamar Alexander, a Tennessee Republican, and Patty Murray, a Washington Democrat, have been pushing a plan in Congress that would restore some government subsidies for insurers who offer policies under Obamacare and lose money, which ought to stabilize and perhaps lower premiums for people buying individual policies. Trump killed those subsidies last year. Some insurers responded by leaving the ACA markets, while others raised premiums to make up the difference. ACA enrollees are protected against large premium hikes, because the law sets an out-of-pocket maximum, with the rest covered by the government. But people buying individual policies without subsidies have no such protection, which has made them easy targets for price hikes during the last several years.

The Alexander-Murray bill would take some of the pressure off such buyers, perhaps even lowering their premiums. But that bill has essentially died, over the usually fractious issue of taxpayer funding for abortions. So, maybe next year. Or maybe never. There are other bills in Congress that might help bring premiums down, but they’re generally stuck amid partisan do-nothingism. “It’s a very fixable problem,” says economist Sara Collins of the Commonwealth Fund. “There are ways to control costs. It’s a frustrating political environment to be in.”

President Trump’s one big initiative in 2018 has been a plan to lower prescription drug prices. But Trump took a pass on the biggest way to do that, which would be pressing for a new law allowing Medicare to negotiate drug prices directly with pharmaceutical firms—an approach he used to favor. Instead, Trump’s plan calls for a series of smaller moves, such as making drug prices more transparent to consumers and allowing pharmacists to advise patients on cheaper alternatives to drugs they’re prescribed. The plan includes some good ideas, but they’re also the sort of proposals that intensive industry lobbying routinely grinds into dust.

Democrats think there’s a void on health care policy that leaves them a big opening in the November midterms, and they could be right. But Democratic proposals—and there are at least five of them—all call for an expanded government role in health care, something much of the public is leery about. There’s also the pesky issue of where to get the money for more public funding of health care, at a time when the government’s annual deficits are likely to start topping $1 trillion. One Democratic idea is to reverse some of the Trump tax cuts, and use that money for health care. But that would put the Democrats in the position of advocating tax hikes, which is never popular in an election year. Invoking Stormy Daniels is a lot easier.